A nurse is preparing to transfer a client who is immobile and weighs 104.3 kg (230 lb) from the bed to a stretcher. Which of the following actions should the nurse plan to take?
Apply a transfer belt to the client prior to transferring to the stretcher.
Move the client onto the stretcher using a slide board with the assistance of two health care workers.
Have the client roll onto a transfer board and pull the board onto the stretcher.
Move the client's upper body onto the stretcher first.
The Correct Answer is B
Rationale
A. Apply a transfer belt to the client prior to transferring to the stretcher: Transfer belts are used for clients who can stand or provide some degree of weight-bearing support. An immobile 104.3-kg client cannot safely assist with the transfer, making the belt ineffective and unsafe. Using a transfer belt in this scenario increases the risk of falls and caregiver injury.
B. Move the client onto the stretcher using a slide board with the assistance of two health care workers: A slide board reduces friction and allows the client to be moved laterally as a single unit, which is the safest method for an immobile client of this weight. Using at least two trained staff members prevents strain and ensures coordinated movement.
C. Have the client roll onto a transfer board and pull the board onto the stretcher: This technique requires the client to participate by rolling, which is not feasible for someone who is immobile. Pulling a transfer board with the client on it creates unnecessary shear forces that increase the risk of skin breakdown. This approach is neither safe nor appropriate for a heavy, immobile patient.
D. Move the client's upper body onto the stretcher first: Moving the client unevenly in sections can cause spinal misalignment and increases the risk of caregiver injury due to poor body mechanics. This technique also creates friction on the client’s skin and may cause discomfort or tissue injury. A coordinated lateral transfer keeps the body aligned and is recommended.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale
A. Keep the head of the client's bed at 30° or less: Elevating the head of the bed to 30° or less reduces pressure on the sacrum and heels, which are common sites for pressure injury in immobile clients. Maintaining this position helps prevent shear and friction forces that contribute to skin breakdown.
B. Bathe the client with soap and hot water: Using soap and hot water can strip natural oils from the skin, increasing dryness and the risk of breakdown. Gentle cleansing with lukewarm water and mild, pH-balanced soap is recommended to preserve skin integrity.
C. Slide the client up in bed every 2 hr: Sliding the client up in bed creates shear and friction forces on the skin, which can exacerbate pressure injuries. Repositioning should involve lifting or using a draw sheet to move the client safely without dragging the skin.
D. Massage bony prominences four times daily: Massaging bony prominences can damage underlying tissue and worsen skin breakdown. Pressure should be relieved through repositioning and support surfaces rather than direct massage of high-risk areas.
Correct Answer is C
Explanation
Rationale
A. No response to tactile stimuli: Lack of response to tactile stimuli indicates a problem with the sense of touch, not hearing. Assessing tactile response helps evaluate somatosensory function rather than auditory function.
B. Presence of expressive aphasia: Expressive aphasia is a language disorder usually caused by neurological injury, such as a stroke, and is not directly related to hearing loss. It affects speech production rather than auditory perception.
C. Decreased attention span: A client with a hearing deficit may have difficulty following conversations or instructions, which can manifest as decreased attention or apparent inattentiveness. Difficulty processing auditory information is a common indicator of hearing impairment.
D. Persistent repositioning of objects: Frequently moving or rearranging objects is more indicative of cognitive or organizational issues rather than a hearing deficit. This behavior does not typically reflect impaired auditory function.
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